Part 3 of 4 in a series: SNF vs Homecare: An examination of the distinction in the provision of clinical services between SNF vs homecare settings
The distinction between clinical services in SNF vs Homecare lies between 4 main points: the number of key providers within the patient’s immediate care plan, the source of reimbursement, the time frame between start of care and discharge, and the environmental scope of a patient’s rehabilitation.
This multi-part series aims to examine each of these points of distinction with a focus on Occupational Therapy. This multi-part series aims to examine each of these points of distinction with a focus on Occupational Therapy. If you missed them, read parts one and two on the blog.
The Time Frame Between Start of Care and Discharge: Occupational Therapy Services Within a SNF and Homecare Setting
“Time is relative,” as the saying goes. In rehab, time, as related to patient care, commences the start of care and continues until discharge. Clinical service time within the Skilled Nursing Facility (SNF) and Homecare is measured in minutes or units – blocks of time. In both settings, there is also billable time, unbillable time, minutes of direct time, untimed minutes, lunchtime, travel time, clocked time in, clocked time out, and the blessed time off. It is within these various perspectives of time that therapists must provide high quality care.
Start of Care and Plan of Care
A patient’s start of care within an SNF begins upon admission and evaluation. Within homecare, a patient’s start of care begins on the date of the first session within the patient’s home, the same date as the evaluation. Evaluations are used to determine the patient’s Plan of Care (POC). The POC is the backbone of a patient’s service plan from start of care to discharge. It includes the rehabilitation diagnosis, a summary of the treatment plan and goals based on the level of functional deficits addressed in the evaluation, the intensity, duration and frequency of care, and the prospective discharge plans. Both the treating therapist and the patient’s referring physician, sign off on the POC.
PTs, OTs and SLPs must strive to utilize both evidenced-based practice (EBP) and a patient-centered approach during evaluation and when formulating a POC in order to assure that the services they provide are meaningful, reimbursable, and clinically relevant to the patient’s medical and rehabilitation diagnoses. However, effectively combining EBP and patient centered approaches is a common challenge among practitioners, most frequently reported when working entry-level positions or when switching from one type of setting to another. Some therapists may have difficulty finding or accessing relevant standardized tests and assessments that can be used for an evaluation, especially if they feel isolated as a homecare therapist, without a team present for guidance and advice. Others may have difficulty synthesizing assessment results and connecting them to meaningful patient-centered goals.
Utilizing Evidence-Based Practice and Data Driven Decision Making to Inform an Evaluation and POC
A 2017 study in the Journal of Occupational Therapy Education considered the use of systematic data driven decision making (DDDM) as a method of increasing the use of evidence-based reasoning, care planning, and communication between occupational therapy fieldwork students, fieldwork educators (FWEs), and patients.[i] The study evaluated the fieldwork students’ knowledge and attitudes regarding EBP and DDDM using a pre- and post- questionnaire, a rubric for objectively scoring the students’ skills in DDDM, and a focus group for FWEs discussing how the use of DDDM impacted students’ knowledge, patient outcome, and occupational therapy practice.
The DDDM framework included: Identification of the patient’s strengths and participation challenges, Identification of the Theoretical Perspective best used to guide clinical intervention, Comprehensive Assessments, Hypothesis based on assessments and other factors affecting patient’s current function and functional potential, Goal Development, Identification of Appropriate Outcome Measures, Setting the Stage for Intervention by determining frequency, intensity, duration and environment for intervention to take place, Intervention, and the Process of Measurement and Monitoring Patient Progress.
Results of the study noted students’ attitudes towards the use of EBP and DDDM within clinical practice did not significantly change, however, findings showed a significant change in students’ skills and knowledge when applying EBP and DDDM to practice. The study considered whether the lack of significant change in student’s attitudes toward EBP and DDDM may have been because they already had learned from their school curriculum the importance of utilizing EBP in practice, but they initially lacked the skills and knowledge to do so in the field. However, once the DDDM framework was applied, FWEs reported greater confidence in their own ability and that of students to link evidence to practice, as well as a way of structuring communication between FWEs, students, and patients regarding patient plan of care. This begs the question: if the importance of EBP is understood by students, and the use of a framework such as DDDM helps therapists to synthesize clinical reasoning and better communicate with colleagues, mentees and patients, then why is there such a breakdown in the consistent use of EBP and DDDM in practice?
Granted, this was a study focused on fieldwork, and both the FWEs and students acknowledged that there was considerable time required in order to learn how to implement DDDM into practice. The concerning “real world” truth is that outside of a study focusing on educators, occupational therapy therapists may feel there is not enough time to assess and document EBP and DDDM within a clinical facility’s fast-paced setting, as is common in a SNF environment. In a “something’s gotta give” situation, they often wonder if it is possible to reduce the time spent during the evaluation and ongoing progress assessment process while still adhering to EBP, DDDM, and patient-oriented care. Is it possible to garner an immediate understanding of a patient’s needs through a more time-efficient means of assessment?
Assessing and Documenting Treatment: The Use of Subjective and Objective Assessments
Both SNF and homecare therapists often utilize the “SOAP” note as a template for documenting patient progress by considering the patient’s subjective self-assessment of their treatment, observing their functional and clinical status, assessing their subjective and observed progress toward their goals, and planning further treatments to maximize their functional potential toward their goals and discharge.
In the interest of reducing the time it takes to assess and document patients’ progress, a 2014 study in the Scandinavian Journal of Occupational Therapy[ii] considered whether similar results could be derived from patients’ subjective self-assessments (inner perspective) and therapists’ clinical observations using objective assessments (outer perspective). The study utilized the Activities of Daily Living Interview Instrument (ADL-I) [iii] [iv] in order to obtain patients’ subjective perception of their functional ability to perform ADLs based on self-report. The assessment tool used to objectively measure the patients’ ADL performance was the observation-based Assessment of Motor and Processing Skills (AMPS), [v] [vi]which considers the patient’s level of fatigue/ effort, efficiency, safety, and independence. A similar study using both the ADL-I and the AMPS when assessing a rheumatologic population [vii]had revealed no significant relationship between the two assessments and had concluded that both subjective and observational assessments must be utilized in order to obtain a thorough evaluative understanding of patients’ functional performance. This study aimed to consider the use of both the ADL-I and the AMPS to assess a completely different, though clinically relevant population of adults with depression. Previous studies have also considered self-reports and level of independence when assessing ADLs within this population, revealing no significant relationship, but none of them have investigated the quality of performance and various other factors when using the AMPS tool.
The results of the study found that while patients would score themselves low on the ADL-I and reported difficulty completing ADLs, and thus required assistance from others, the majority of them scored within age-related expectations for motor ability and processing ability during ADL activities when assessed using the AMPS. While there was no significant relationship between the subjective and objective assessments within this population, much like the results in previous studies, the consistent results of all of these studies put together inform occupational therapy practice regarding the necessity of utilizing both subjective and objective assessments.
The example provided in this study considered an adult with depression, physically capable of to completing an ADL, as observed using the AMPS, but may report on the ADL-I the inability to complete the same activity due to factors unrelated to decreased motor and processing skills. Factors such as increased fatigue, decreased motivation, the inability to safely perform the activity, or even feelings of perceived dependency based on the amount of possible over-assistance provided can provide further insight into the bigger picture. In other words, though we may feel pinched for time during the evaluative and re-evaluative processes, we cannot afford to sacrifice one type of assessment for the other, lest we miss out on the bigger picture– that of the “whole patient”.
Time, as Related to the Life of an Occupational Therapist in Skilled Nursing Home Facilities and Homecare
The POC is the outline depicting the time frame from a patient’s start of care to discharge, and it is utilized in both the SNF and Homecare. However, occupational therapists also must be cognizant of their own day-to-day time. Balancing a caseload requiring treatments and evaluations, creation of POCs, assessments, documentation based on EBP, as well as care team meetings, and all the additional and often unbillable but time-consuming work requirements is all time consuming.
Within an SNF, the productivity of rehabilitation staff is often scrutinized. A therapist’s productivity is often calculated by the number of treatment minutes they provided over the course of the day (sometimes with a little lenience for time spent in care planning meetings and doing documentation), divided by the number of hours they have “clocked” in the facility. Right before logging out of the computer for the day, a score flashes in red. Some therapists can manage 96% but others may be at 76%. Does this empirical calculation account for quality of care? While the best-case scenario is that a productivity score allows for Rehab Directors and Rehab Managers to keep track, does it inspire the therapist to work harder – or smarter? What implications might this have on day-to-day clinical practice in the longer-term?
Homecare therapists may not feel the immediate pressures of productivity from supervision or administrative staff, given the nature and setting of their work. Nevertheless, pressure persists in other forms. Non-patient factors may creep into workday, such as travel time and important but unbillable pre- and post-session equipment or activity set-up, or the documentation itself. Some companies do not allow for time to be billed for documentation, leaving the therapist to make the choice whether or not to reduce treatment time in lieu of paid documentation time.
Such time pressures can lead therapists to feel helpless, ineffective, and may lead to burnout. A study conducted via postal questionnaire in 2014 and published in the Scandinavian Journal of Occupational Therapy considered high job demands and lack of time within occupational therapy practice.[viii] The 472 responders rated perceived overall stress on a scale for 49 factors including: “Too much work to do in a limited time,” “Excessive administrative tasks limit patient time,” “Lack of time to plan or evaluate treatments,” and “Constant Interruptions.” However, the only factor significantly associated with a high level of overall stress by the majority of the respondents was “Working at a superficial level due to lack of time.” The study discussed the concerning risk of compromised “work engagement” due to their findings. They defined work engagement as a therapist’s “energy, involvement, and professional efficacy.”
This is most concerning to the future of the therapy profession. As important as it is to maintain standards of practice, it’s also important to uphold professional standards. There was a positive finding to the 2014 questionnaire study in that the responders seemed confident regarding their professional identity and role within the workplace. It can be inferred from both the positive and negative findings that OT’s stress is derived from knowing what is expected, seeking to meet that expectation, but without enough perceived time in the work day to do so. Is it possible to resolve the problem of perceived lack of time within the workday? What sort of supports are there for therapists who feel they are stressed and unable to find a resolution to meeting professional expectations within the limitations of time?
The American Physical Therapy Association’s Center for Integrity in Practice has partnered with the American Occupational Therapy Association (AOTA)[ix], as well as the American-Speech-Language-Hearing-Association (ASHA) to analyze and advocate for therapists and their environments in order to assure professionalism, compliance, integrity, and appropriateness of provider care, and to limit instances of fraud, abuse, and waste. They have issued a consensus statement acknowledging that, “Employer policies or practices that conflict with the autonomy of practitioners’ clinical judgment can cause frustration, hardship, and moral distress.[x] Practitioners can feel isolated in their work setting or face negative repercussions when they question these practices.” Within the statement, they have offered resources and possible actions for therapists to take.
[i] Carroll, A., Herge, E., Johnson, L., & Schaaf, R. (2017). Outcomes of an Evidence-Based, Data Driven-Model Fieldwork Experience for Occupational Therapy Students. Journal of Occupational Therapy Education, 1 (1).
[ii] Nielsen, Kristina Tomra, and Eva Ejlersen Wæhrens. “Occupational therapy evaluation: use of self-report and/or observation?”Scandinavian Journal of Occupational Therapy 22.1 (2014): 13-23.Informa Healthcare. Web. 10 Aug. 2017.
[iii] Wæhrens EE. Measuring quality of occupational performance based on self-report and observation: Development and validation of instruments to evaluate ADL task performance. Dissertation Department of Community Medicine and Rehabilitation, Occupational Therapy, Umeå University; Sweden: 2010.
[iv] Wæhrens EE. ADL-I Manual, research version; February 2011–unpublished.
[v] Fisher AG, Jones KB. Development, standardization and administration manual. In Assessment of motor and process skills. Volume 1 7th edition. revised Three Star Press; Fort Collins, CO: 2012.
[vi] Fisher AG, Jones KB. Assessment of motor and process skills: user manual. Volume 2 7th edition. revised Three Star Press; Fort Collins, CO: 2012.
[vii] Wæhrens EE, Bliddal H, Danneskiold-Samsøe B, Lund H, Fisher AG.. Scand J Rheumatol 2012;41:95–102.
[viii] Wressle, Ewa and Kersti Samuelsson. “High Job Demands and Lack of Time: A Future Challenge in Occupational Therapy.” Scandinavian Journal of Occupational Therapy, vol. 21, no. 6, Nov. 2014, pp. 421-428.
[ix] Bellamy, Jason. “Partnerships and Collaboration.” APTA Center for Integrity in Practice. N.p., 14 Oct. 2014. Web. 13 Aug. 2017. http://integrity.apta.org/AboutUs/PartnershipsCollaboration/
[x] “Consensus Statement on Clinical Judgment in Health Care Settings.” Consensus Statement on Clinical Judgment in Health Care Settings, AOTA, APTA, ASHA, integrity.apta.org/ConsensusStatement/. http://integrity.apta.org/ConsensusStatement/